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Potential Liability Incident Report TC-2 - Nevada

Potential Liability Incident Report Form. This is a Nevada form and can be used in Office Of Attorney General Statewide .
 Fillable pdf Last Modified 4/12/2016
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State of Nevada Potential Liability Incident Report INSTRUCTIONS: State Agency should use this form to report potential liability claims against the State This "Incident Report" should be sent ASAP to: Claims Manager, Office of the Attorney General · Interdepartmental Mail, or · Via fax to 775-684-1108, or · 100 North Carson Street, Carson City, NV 89701-4717 If an individual wishes to make a formal claim against the State, the individual should contact the Office of the Attorney General at TEL: 775-684-1252 or 775-684-1263; FAX 775-684-1108. The Attorney General's office will send the appropriate form to the injured/damaged party PLEASE NOTE: Do not use this form to report injuries of State employees. A Worker's Compensation injury report must be filed in those instances. Please type or print clearly Name of Injured/Damaged Party: Mailing Address: Telephone #: Date of Incident: Time: Location where incident occurred (include street address): Department: Division: Contact Person: _____________________________________________________ ________________________ Budget Account: Title: Telephone #: TC-1 Claim form provided to injured/damaged party? Yes No (http://ag.nv.gov/uploadedFiles/agnvgov/Content/Complaints/TC1.pdf) Please provide a detailed description of what happened and attach all supporting documentation you may have. (Attach additional pages/photographs, if necessary): Form completed by: TC-2 (Form revised 4/2014) Office of the Attorney General Date: American LegalNet, Inc. www.FormsWorkFlow.com
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